Funeral Or Burial Funds Act Annual Forms Page 4
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11ANNUAL STATEMENT OF FUNERAL OR BURIAL TRUST FUNDS
Summary of detailed schedules
Held by Independent Trustee(s)
PRINCIPAL
INTEREST
TOTAL
(If applicable)
(A)
(B)
(C)
1
Total amount of funds, start of year
2
Total additions during fiscal year
3
Subtotal (Add lines 1 and 2)
4
Total withdrawals during fiscal year
5
Total amount of funds, end of year
If funds are entrusted with more than one independent trustee, you must provide a detailed schedule reflecting the total amount of
funds held by each independent trustee.
Held by Licensee as Trustee
(If applicable)
(A)
(B)
(C)
6
Total amount of funds, start of year
7
Total additions during fiscal year
8
Subtotal (Add lines 6 and 7)
9
Total withdrawals during fiscal year
10
Total amount of funds, end of year
If funds are held at more than one location, you must provide a detailed schedule reflecting the total amount of funds held at each
location.
Grand Total — Trust Funds
(must complete)
(A)
(B)
(C)
(1A plus 6A)
(1B plus 6B)
(1C plus 6C)
11
Total amount of funds, start of year
(Total of lines 1 + 6)
(2A plus 7A)
(2B plus 7B)
(2C plus 7C)
12
Total additions during fiscal year
(Total of lines 2+ 7)
(4A plus 9A)
(4B plus 9B)
(4C plus 9C)
13
Total withdrawals during fiscal year
(Total of lines 4+ 9)
(5A plus 10A)
(5B plus 10B)
(5C plus 10C)
14
Total amount of funds, end of year
(Total of lines 5+ 10)
Insurance/Annuity (Funds)
Beginning of Year
End of Year
Total Premium Paid
Face Amount
Face Amount
During Fiscal Year
If more than one insurance company is utilized, you must provide a detailed schedule reflecting
the total amount of funds for each insurance company.
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